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Resuscitation 80 (2009) 898–902

Contents lists available at ScienceDirect

Resuscitation

journa l homepage: www.e lsev ier .com/ locate / resusc i ta t ion

imulation and education

ospital employees improve basic life support skills and confidence with aersonal resuscitation manikin and a 24-min video instruction�

onrad Arnfinn Bjørshola,∗, Thomas W. Lindnera, Eldar Søreidea, Leif Moenb, Kjetil Sundec

Department of Anaesthesia and Intensive Care Medicine, Stavanger University Hospital, Stavanger, NorwayDepartment of Internal Service, Stavanger University Hospital, Stavanger, NorwayDepartment of Anaesthesiology and Institute for Experimental Medical Research, Oslo University Hospital, Oslo, Norway

r t i c l e i n f o

rticle history:eceived 30 March 2009eceived in revised form 28 May 2009ccepted 5 June 2009

eywords:ardiopulmonary resuscitation (CPR)asic life support (BLS)raining

a b s t r a c t

Introduction: The use of a personal resuscitation manikin with video instruction is reportedly as effectiveas traditional instructor-led courses in teaching lay people basic life support (BLS). We applied this methodto an entire hospital staff to determine its effect on their practical and self-judged BLS skills.Methods: All 5382 employees at Stavanger University Hospital were asked to learn or refresh their BLS skillswith the personal resuscitation manikin and video instruction. Prior to and nine months after training,all employees were asked to rate their BLS skills on a scale from one to five. Additionally, randomlychosen study subjects were tested for BLS skills pre-training and six months post-training during 2 minof resuscitation on a manikin.Results: In total, 5118 employees took part in the BLS training program. The number of correct chest

compressions increased significantly from 60 (5–102) to 119 (75–150) in the pre- vs. post-training periods,respectively, P < 0.01, but the number of correct MTM ventilations did not change. Self-reported BLS skillsincreased from 3.1 (±1.0) pre-training to 3.8 (±0.8) post-training, P = 0.031.Conclusion: After distributing a personal resuscitation manikin with video instruction to an entire hospitalstaff, the median number of correctly performed chest compressions doubled and self-confidence in BLSskills improved significantly. This is a simple and less time-consuming method than instructor-led courses

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in preparing hospital emp

. Introduction

About one-third of all cardiac arrests occur in hospitals,1 bothn and out of critical care areas. As for out-of-hospital cardiacrrest, survival depends on a sequence of interventions—the chainf survival.2 Cardiopulmonary resuscitation (CPR) is a central partf this, and the incidence of attempted CPR outside critical carereas has previously been reported to be 1.3 per 1000 admissions,3

nd personnel in these areas have less training and experience withhe management of cardiac arrest.

Outside critical care areas the witnessing hospital employeehould be able to recognise the arrest, call for help and perform basicife support (BLS).4 Early BLS increases the chances of survival fromentricular fibrillation 2–3-fold.5 Therefore, all health care profes-

� A Spanish translated version of the abstract of this article appears as Appendixn the final online version at doi:10.1016/j.resuscitation.2009.06.009.∗ Corresponding author at: Department of Anaesthesia and Intensive Careedicine, Stavanger University Hospital, P.O. Box 8100, N-4068 Stavanger, Norway.

el.: +47 99733818.E-mail address: bjco@sus.no (C.A. Bjørshol).

300-9572/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.oi:10.1016/j.resuscitation.2009.06.009

es in the basic handling of cardiac arrest.© 2009 Elsevier Ireland Ltd. All rights reserved.

sionals should be able to demonstrate competency in BLS skills,6

and in a recent study hospital employees were generally motivatedto learn BLS.7

Failure to perform good quality BLS according to currentguidelines,8–11 and poor skill retention is common among bothhealthcare professionals and lay people.12 Traditionally in-hospitalBLS training in our hospital consisted of time-consuming, expen-sive and unpractical 1-h courses with a maximum of 10 pupils perinstructor. However, students have demonstrated better BLS skillsafter being taught by peer students than by professionals.13 Theuse of video instruction14,15 or voice advisory manikins16 has beenshown to be effective and feasible BLS training methods, and cogni-tive skills of BLS increase by using multimedia or case discussions.17

Further, the rate of bystander CPR has been shown to increase in apopulation following television announcements.18 Recently, per-sonal resuscitation manikins with video instruction were reportedto be as effective as traditional CPR courses in BLS training of lay

people.19–22 This training concept, however, has not been reportedfor hospital employees.

In 2006 the hospital Board of Directors at Stavanger Univer-sity Hospital (SUH) initiated a campaign with the intention that allhospital employees should become proficient providers of BLS by

C.A. Bjørshol et al. / Resuscitation 80 (2009) 898–902 899

Table 1Questionnaire administered to all hospital employees before receiving their personal resuscitation manikin.

Question Answer Number of replies

What is your age? 43 (±11) years 3445

What is your gender? Female: 87% 3298Male: 13%

How long ago did you have training in basic lifesupport (BLS)?

15 (8–60) months 3295Never: 296

How well do you feel that you are trained in BLS (1–5, 1 = very bad and 5 = very good)? 3.1 (±1.0) 3412

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ave you been in a situation where you neededskills in BLS, whether at work or not?

eceiving a personal resuscitation manikin with video instruction.he aim of this study was to assess whether this BLS training con-ept could improve hospital employees’ self-reported confidencend practical basic BLS skills.

. Methods

.1. Stavanger University Hospital (SUH)

SUH provides service to a population of 300,000 people. SUHas 905 beds (both somatic and psychiatric) and 5382 employ-es. In-hospital cardiac arrests (IHCAs) occurring outside criticalare areas (Intensive Care Units, Coronary Care Units, Emergencyepartment and Operating Theatres) receive BLS by the attendingmployees and, following emergency activation, with advanced lifeupport by a designated IHCA team. Prior to November 2006, BLSraining was offered only to selected health care professionals andas unsystematically organised by instructors within individualepartments.

.2. BLS training with the MiniAnne concept

In November to December 2006, all SUH employees, regardlessf prior training, were offered a personal resuscitation manikinLaerdal MiniAnne, Stavanger, Norway) with a 24-min videonstruction on DVD. The hospital employees were given three dif-erent training possibilities:

. in a hospital meeting room available for everyone, the video wasshown every hour during daytime, played by a coach, for ninedays in a room with enough space for up to 50 employees to prac-tice simultaneously on the floor. All employees were encouraged

to participate;

. those not willing to or not able to attend these sessions couldpractice with their own manikin and DVD in their actual workingenvironment (with colleagues or on their own);

. at home.

able 2uestionnaire to all hospital employees nine months after receiving their personal resusc

uestion

here did you perform the BLS training withyour MiniAnne manikin?

ow long ago did you train with your MiniAnne manikin?

ow well do you feel that you are trained in BLS (1–5, 1 = very bad and 5 = very good)?

ow many persons, in addition to yourself, have trained on BLS with your MiniAnnemanikin/self-instruction movie?ave you experienced any discomfort using themanikin?

Yes, at work: 1121 (33%) 3425Yes, outside work: 363 (11%)No: 2071 (60%)

Besides these optional training possibilities, no further BLS instruc-tions were provided. All training was voluntary.

2.3. Study design

The study consisted of two separate BLS skills assessments:self-reported confidence and practical skills. Both of these two inde-pendent BLS skills assessments were tested twice: before and afterthe campaign. All study subjects signed an informed consent doc-ument before participation. No further approval was required.

2.3.1. Self-reported BLS skills—questionnairePrior to receiving their personal manikin, we asked all employ-

ees to complete a questionnaire concerning their experience andself-judged skills in BLS (Table 1). Approximately nine months lateranother questionnaire was distributed to all hospital employeesby internal mail (Table 2). Again, their self-judged BLS skills wereassessed together with questions about their training experience.

2.3.2. Practical BLS skills—manikin studyTo evaluate individual effects of the BLS training, 62 hospital

employees from different departments were randomly chosen froma list of all hospital employees, but excluding personnel working atcritical care areas.

Upon inclusion, the study subjects, without any preparationor knowledge of the study concept, were presented with a sim-ulated cardiac arrest. They were told that they had just found anapparently unconscious 50-year-old woman on the ground. Shewas represented by a MiniAnne equipped with a counting device.This counting device measured the number of correct chest com-pressions (compression force >35 kg) and mouth-to-mouth (MTM)ventilations (chest rise) during the first 2 min after initiation of BLS,

and the results were displayed on a small screen not visible for thestudy subjects. In addition, all actions taken by the study subjectswere documented manually. After completing this test they weregiven a personal resuscitation manikin with video instruction andencouraged to use it actively.

itation manikin.

Answer Number of replies

Hospital meeting room: 908 (65%) 1397Own dept.: 366 (26%)At home: 73 (5%)Did not participate: 120 (9%)

39 (26–48) weeks 1184

3.8 (±0.8) 1333

1 (0–3) 1165

Yes: 49 (4%) 1272No: 1223 (96%)

900 C.A. Bjørshol et al. / Resuscitation 80 (2009) 898–902

Table 3Number of study subjects performing different BLS tasks before and six months after BLS training with a personal resuscitation manikin and video instruction (percentagesin brackets). The number of correct chest compressions and mouth-to-mouth ventilations are measured for 2 min after initiation of BLS (interquartile range in brackets).

Before BLS training, n = 59 Six months after BLS training, n = 39 P value

Assessed responsiveness 42 (71) 34 (87) 0.02Opened airways before assessing respiration 10 (17) 17 (44) 0.01Assessed respiration 42 (71) 28 (72) 0.73Pulse check 34 (58) 13 (33) 0.02Called for help before starting BLS 45 (76) 32 (82) 0.61CCNN

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orrect telephone number for EMS activation 56 (98)orrect compression:ventilation (C:V) ratio 32 (54)umber of correct chest compressions 60 (5–102)umber of correct mouth-to-mouth ventilations 3 (0–8)

Approximately six months later, a second test was repeatedmong available study subjects from the pre-training test.

.4. Costs

We calculated the cost for this campaign as price paid for theanikins and time spent organising and running the campaign.

.5. Statistical analysis

The questionnaire responses concerning self-judged BLS skillsere compared using Student’s t-test. In the manikin study, theumber of correct chest compressions and MTM ventilations wasompared with Wilcoxon Signed Ranks test as they were not nor-ally distributed. The other actions performed were compared

sing McNemar test. Results are reported as mean ± SD when nor-ally distributed, otherwise as median with interquartile range. Avalue of less than 0.05 was regarded as statistically significant.

tatistical analyses were performed using SPSS version 14.0.

. Results

Altogether, 5118 manikins were distributed, indicating that 95%f the hospital employees received a personal manikin. Among allospital employees, 3466 (68%) replied to the first questionnaireTable 1); the majority of these were women (87%). Of the respon-ents, 2.999 (91%) had previous BLS training median 15 (8–60)onths earlier, 296 (9%) reported that they had never been trained

n BLS, while 1354 (40%) had needed BLS skills whether at or outsideork (Table 1).

Altogether 908 (65%) respondents to the second questionnairead attended the classroom training while 366 (26%) had beenrained in their own department and 73 (5%) at home (Table 2).nly 120 (9%) of the respondents to the second questionnaire didot participate in the training, mainly because they had been on

eave of absence or were employed after the MiniAnne campaignTable 2). Noteworthy, 49 employees (4%) reported some kind ofiscomfort after training with their manikin, including 40 reportsf bruising or swelling around the mouth or on the hands.

.1. Self-reported BLS skills

Mean score for pre-training self-rated competence in BLS was.1 (±1.0). This score increased to 3.8 (±0.8) nine months after BLSraining, P = 0.031.

.2. Practical BLS skills

Three hospital employees refused to participate because of backain, leaving 59 subjects for pre-training evaluation. Of these, fivead never before had any training in BLS. Six months after receivingheir personal manikin, 39 of these were available for the second

39 (100) ns36 (98) <0.001

119 (75–150) <0.0014 (0–7) 0.23

BLS test (Table 3). The number of correct chest compressions andthe number of study subjects using correct compression:ventilation(C:V) ratio increased post-training vs. pre-training (Table 3). Fewersubjects checked for a pulse post-training, while the number ofcorrect MTM ventilations did not change (Table 3).

3.3. Costs

The 5400 manikins had a price of 28.41 Euro each (incl. VAT),totalling 153,414 Euro. In addition, 11 employees worked a totalof 370 h organising and running this campaign, representing 4 minper employee trained. This is added to 30 min each employee spentduring the training.

4. Discussion

This study demonstrated that the use of a personal resuscitationmanikin with video instruction can improve BLS performance for upto six months for hospital employees, including both professionalhealth care providers and employees with minimal or no patientcontact. To our knowledge, this is the first study involving the train-ing of an entire hospital staff using the MiniAnne manikin. As thisis less time-consuming than traditional instructor-led courses, thismay be a useful alternative for BLS training and skill maintenancefor hospital employees.

In-hospital early attendance by a cardiac arrest team and earlydefibrillation is the gold standard.23 As initial asystole and pulse-less electrical activity (PEA) are common in IHCAs,24 it is imperativethat initially responding employees are confident and able to initi-ate BLS. BLS initiation within the first minute of cardiac arrest hasbeen shown to double the survival to discharge after IHCA.25 Hospi-tals should optimise the in-hospital chain of survival, and both AEDprograms25,26 and BLS training are important. Consistent with pre-vious studies,27 40% of employees had already needed BLS skills,which further emphasises the need for BLS skills among hospitalemployees.

It has been reported that physicians and nurses feel thatCPR training is insufficient.28,29 A main problem with previousin-hospital BLS training was that it was time-consuming andunpractical related to the daily work at the wards. It also had tobe repeated regularly, often resulting in the exclusion of personneloutside critical care areas. These time-constraints may be overcomewith the MiniAnne BLS training concept, as we have demonstrated.Moreover, the costs of the present BLS teaching campaign are mod-est. Direct comparison of costs, however, is impossible, as the totalcosts of such traditional in-hospital BLS courses have never beendescribed.

For lay people, the use of a personal resuscitation manikinwith video instruction has been shown to have a similar effecton BLS skills as traditional instructor-led CPR courses bothimmediately19,22,30 and up to six months after training.20,21 Pre-vious studies with traditional CPR courses have shown a general

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ecline in performance after six to nine months12,31 but withoutdecline in chest compression depth and ventilation volume.12,31

n the present study, the median number of correct chest compres-ions per minute doubled from 30 to 60 at the six-month follow-up,ith a significant increase in the use of correct C:V ratio. Further, theumber of subjects checking for a pulse was significantly reducedt the six-month follow-up. All of these factors are in accordanceith present guidelines,5 and reduce the amount of unnecessaryands-off intervals and therefore improve the quality of BLS.

Self-reported BLS skills were also increased nine months afterraining. Self-reported CPR skills have previously been shown toave no correlation32 or correlate only weakly33 with practical CPRkills, but a recent study has demonstrated an association betweenelf-confidence and quality of both compression and ventilationkills.34 We believe that an increase in BLS confidence will increasehe likelihood that hospital employees will perform BLS if theyncounter a patient with cardiac arrest.

There are some limitations to the present study. The countingevice within the MiniAnne cannot measure the exact chest com-ression rate, compression depth or hands-off time, all of whichre correlated to outcome. The compression force of 35 kg for cor-ect chest compressions does however correlate well with averageompression force for cardiac arrest patients.35 There is also noeasurement of ventilation rate or volume. Further, we do not

now if the employees watched the video and trained on theanikin more than once. Also, the observer was not blinded to the

tage of training for the study subjects as the assessments wereade at different time periods. We further do not know what pro-

ortion of employees that are regularly exposed to cardiac arrestnd hence might have more practice.

While the information strategy prior to this teaching campaigns well as the social effect of the training might partly explain thempressive participation in this BLS training, the majority of partici-ants trained in the hospital meeting room. This was not surprisings they were encouraged to do the training during working hours.t is not a direct study limitation, but might be another importantactor in our continuous efforts to improve BLS skills, and that theresent results cannot automatically be assumed to be extrapo-

ated to other situations. We do not know the participation rate oresults if they were instructed to train only at home. However, it ismportant to emphasise that all training was based on a volunteerarticipation.

Assessing study subjects before the teaching campaign mightlso have a teaching effect. Using identical tests at different timess known to affect the results, as the study subjects learn the test anderform better on subsequent examinations.36 Further, we do notnow if the improvement in BLS performance in this study leads tomproved quality of BLS in real cardiac arrests. Finally, the increasen self-confidence following BLS training could be due to the shortnterval from training to the second questionnaire (nine months)ompared to time since last BLS training before this campaign (15onths) instead of the training method itself, as more frequent

raining increases self-assessed competence in BLS.37

. Conclusion

A hospital-wide BLS learning campaign with a personal resus-itation manikin and video instruction improved both employeeelf-confidence and practical BLS skills. This is a less time-onsuming option to instructor-led courses to improve the firstinks in the in-hospital chain of survival for IHCA patients.

onflicts of interest

CAB and TWL have 20% employments as facilitators at Stavangercute Medicine Foundation for Education and Research (SAFER).

ion 80 (2009) 898–902 901

ES is medical director at SAFER. CAB, TWL and ES have receivedfinancial support from the Laerdal Foundation for Acute Medicine.

Acknowledgements

Thanks to the committee who organised the BLS training at theStavanger University Hospital, consisting of Kristian Lexow, IngvildMorken, Astrid Høie Bøe, Åshild Hjørnevik, Gunhild Bjørnå, ElsaSøyland, Bente Skarstad and Gunhild Tjensvoll. Thanks also to JuneGlomsaker for supplying lists of employees, Linda Sivertsen forpractical support, Ann-Britt Thorén for scientific advice, Odd BjarteNilsen for statistical advice and Petter Andreas Steen for criticalrevision of the manuscript.

CB has received financial support from the Laerdal Foundationfor Acute Medicine (Bjørn Lind PhD scholarship).

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